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Ann Thorac Surg 1997;64:1222-1223
© 1997 The Society of Thoracic Surgeons

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Correspondence

Rapid Recovery in the Elderly

Starr-Wood Cardiac Group of Portland, PC, 9155 SW Barnes Rd, Suite 240, Portland, OR 97225-6629

To the Editor:

The recent article on rapid recovery in the elderly [1] was greatly appreciated and touches on a very important issue that severely affects heart programs worldwide.

The incidence of atrial fibrillation and the suggested reasons for the low percentage are interesting. Something that is used in that program that may have an additional effect is the use of steroids. The use of a steroid, magnesium, digitalis, and ß-blocker protocol has resulted in an incidence in the neighborhood of 5% at our program in Visalia, California, and in a similar fashion a program in Bismarck, North Dakota, reports an incidence of 7%.

The 4 mg of dexamethasone intravenously every 6 hours during the first 24 hours postoperatively is a reasonable comparison with the 10 mg of dexamethasone given preoperatively in our Visalia program and the daily hydrocortisone sodium succinate for 3 days in the Bismarck program. It would be of interest to try to sort out the specific benefit of steroid and triiodothyronine and see if its effect is additive or isolated.

Reference

1. Ott RA, Gutfinger DE, Miller MP, Alimadadian H, Tanner TM. Rapid recovery after coronary artery bypass grafting: is the elderly patient eligible? Ann Thorac Surg 1997;63:634–9.

Reply

Division of Cardiothoracic Surgery, University of California Irvine Medical Center, Bldg 53, Rt 81, 101 City Dr S, Orange, CA 92668

To the Editor:

Atrial fibrillation (AF), although seldom life-threatening, is an important complication after coronary artery bypass grafting. Because of its impact on average length of stay, major economic consequences result when the incidence of AF is high. Because the occurrence of AF after coronary artery bypass grafting can be multifactorial, combination therapy is logical when attempts to reduce AF are seriously undertaken.

I read with interest the letter by Dr Bietz, who has recognized the importance of AF prevention and suggest that perioperative steroid therapy in combination with magnesium, digitalis, and ß-blockers is responsible for achieving a remarkable 7% incidence of AF after coronary artery bypass grafting. Our experience adds support to these results, and clearly the use of magnesium, digitalis and ß-blockers has gained wide acceptance.

Steroid therapy, initially introduced by Krohn and associates [1] and later used by Engelman [2], improves recovery after coronary artery bypass grafting and shortens average length of stay. If the use of perioperative steroids adds further to the prevention of AF, such results would be welcome news. However, evidence of thyroid hormone replacement significantly influencing AF has been reported [3]; because perioperative thyroid replacement is unlikely to elicit an adverse clinical reaction and the possibility of reducing AF exists, its use should continue to be investigated.

Clearly, the prevention of AF after coronary artery bypass grafting is important to today's cardiac surgeon. However, aggressive treatment of atrial dysrhythmias when they occur should also be emphasized. In our practice the use of intravenous procainamide for frequent premature atrial contractions as well as AF certainly affected the average length of stay in our series.

Although the formula for the perfect AF prevention "cocktail" has not been described, continued efforts in defining effective therapy should be encouraged.

References

1. Krohn BG, Kay JH, Mendezina, et al. Rapid sustained recovery after cardiac operations. J Thorac Cardiovasc Surg 1990;1001:194–7.
2. Engelman RM. Mechanisms to reduce hospital stays. Ann Thorac Surg 1996;61:526–9.
3. Klemperer JD, Klein IL, Ojamaa K, et al. Triiodothyronine therapy lowers the incidence of atrial fibrillation after cardiac operations. Ann Thorac Surg 1996;61:1323–9.[Abstract/Free Full Text]

This article has been cited by other articles:

				M. Hravnak, L. A. Hoffman, M. I. Saul, T. G. Zullo, and G. R. Whitman Resource Utilization Related to Atrial Fibrillation After Coronary Artery Bypass Grafting Am. J. Crit. Care., May 1, 2002; 11(3): 228 - 238. [Abstract] [Full Text] [PDF]

				M. Hravnak, L. A. Hoffman, M. I. Saul, T. G. Zullo, J. F. Cuneo, G. R. Whitman, J. M. Clochesy, and B. P. Griffith Atrial fibrillation: prevalence after minimally invasive direct and standard coronary artery bypass Ann. Thorac. Surg., May 1, 2001; 71(5): 1491 - 1495. [Abstract] [Full Text] [PDF]

This Article Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Duane S. Bietz Richard A. Ott Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Bietz, D. S. Articles by Ott, R. A. Search for Related Content PubMed PubMed Citation Articles by Bietz, D. S. Articles by Ott, R. A.